Podcast 127 – The Oxylator with Jim DuCanto

Today on the show, I talk with my friend Jim DuCanto, MD about the oxylator. Jim is an anesthesiologist extraordinaire with a constant drive to perfect new airway techniques and document them on video along the way.

What is the Oxylator?

A mainly plastic device about the size of your fist with a incredibly quick magnetic valve

It runs on pressurized wall or tank oxygen

Only two main controls, a pressure setting knob and a manual inhalation/automatic mode button

Manual Resuscitator Mode

Press the button and the device will give 30 lpm of inhalation until you let go or it hits the pressure limit you set

Automatic Ventilator Mode

Press in the button and give it a turn and the device switches to automatic ventilation mode. Think of it as a flow-controlled, pressure cycled ventilator in your hand

It gives 30 lpm fixed flow (slow, safe flow) until it hits the user-selectable pressure limit, it then cycles to passive exhalation until it reaches 2-4 cm H20 PEEP and then it begins a new breath

On a patient who is not spontaneously breathing, you can titrate that pressure setting to an inhalation time of 1-2 seconds; this will deliver 500-1000 mls per breath

At those settings, the minute volume will be 10-12 liters/minute

from inter-rescue.de

Feedback

The device indicates when you are obstructing by clicking and tells you when there is a mask seal leak by not cycling to the next breath

It Solves the 5 Problems of the BVM

We give too many breaths

Those breaths are at too high a pressure

The breaths are given too rapidly

We get no feedback on whether the breath went in or it was given against an obstructed airway

In a spontaneously breathing patient, the BVM will give variable FiO2s depending on the exhalation port

How we use it

We both use an inline hepa filter, ETCO2 port, and sometimes extension tubing. If you want to use it on a spontaneously breathing patient, OR mask straps are a great addition.

Two models

EMX (25-45 cm H20) and HD (15-30). There are also specialty models for chemical/explosive situations.

Here is Jim's Overview on the Device

And here are the Slides from a lecture Jim gave at SAM

Here is an example of the use of the Oxylator for an OR Induction

Nasal CPAP in Unconscious Patient is More Effective than Full-Face Masks

Interesting. Brings me back to the 80s when a “demand” valve was on every ambulance and EMTs/first aiders used them. They moved away from them out of fears of overinsufflation. It certainly is much easier to use than the bag. It does not do much for improving the seal. http://en.wikipedia.org/wiki/Resuscitator

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5 years ago

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Patrick Wanner

Interesting material, thank you. In my hospital we primarily use the Oxylator for all in-hospital resuscitations (we’ve got one on every ward). Our code-cart has a BVM, but we got rid of them on the wards since it’s just much easier to adequately oxygenate a patient (and much more difficult to injure them) with an Oxylator. When we introduced the Oxylator, our anesthesia service would bring nurses in to the OR to get a feeling for them in real life, which I found a good idea.

Our ambulance service also has an Oxylator and I’ve seen it used in cardiac arrest situations where only two medical personnel were there and no bystanders were in a position where they could help with chest compressions. Following insertion of a laryngeal tube, the patient could be ventilated automatically (30:2) with one provider doing chest compressions and the other one getting the IV going, drawing up meds, etc., until the second team with the emergency physician (and more manpower) arrived. It’s a very elegant solution in prehospital situations where resources are scarce.

Patrick, can you advise me if you work for a US based system? I am wanting to know how prevalent this devise is in the US vs Europe and Asia. Is it becoming standard use in cardiac arrests for your system? Thanks!

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5 years ago

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Patrick Wanner

Hi Michael, I work in Switzerland. Over here its use is heterogenous and depends very much on the service you work for, as far as I know. Although its use has increased lately, I would say that many of our teams will still use a BVM either due to habit or for some due to preference.

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5 years ago

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Dominic

We been using the oxylator as a standard of care for assisted ventilation for a long time in the prehospital in the province of Québec. It was adopted as a replacement for the pocket mask, because we never agree to use facemask BVM. They also developed a technique of assisted respiration in acute respiratory distress (pretty much like a Bipap) using tubing to increased the death space and setting the oxylator at 20 cm h2o, that will gives 10 cm h2o of inspiration pressure to the patient. http://www.youtube.com/watch?v=j3I2Sb5yVhU

BVM is the devil pendulum swing is unfounded. BVM is tremendous tool, it’s all about using the proper tool for the job. #1 Oxylator is a pneumatically powered device (nothing new here anyone remember bird mark 7 ventilator?). The fact that it’s pneumatically powered or it wont work is a negative in itself. Pneumatically powered devices go through O2 tanks in a few minutes and then what do you have? A device that does not work. “Oxylator requires 2 things in life to work 1) pressurized gas supply wall or tank of 55 PSI) and an open airway and or it will NOT WORK! BVM can still operate without oxygen supply and still deliver FiO2 of 21%. BVM works all the time, does not need pneumatic input and is cheap. Bed cofound patients who develop mucus plugs in the ETT you will get high pressure alarms on the ventilator and when you are trying to trouble shoot you first action would be to d/c the ventilator (most would agree here). BVM will facilitate you feeling decreased compliance as it will very hard to squeeze the bag with a mucus plug. Thus you will know right away to either suction or… Read more »

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5 years ago

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jducanto

Hi Nikolay, Let me expound on the issues you brought forth. 1) Compressed gas consumption: The Oxylator consumes 15 liters per minute during operation, which consumes a full E-cylinder in about 45 minutes, and obviously smaller tanks get consumed more quickly. The device was developed as a Resuscitator, that is, a ventilation device to be used in resuscitation. It can be used as a transport ventilator, but that is not its primary purpose. Gas consumption can be lessened with a flow-reducing hose, which is a device available from the manufacturer that will allow a reduction in the minute ventilation of the device (from 10-12 liter per minute minute ventilation to as low as 4.5 liters per minute). This flow changing hose allows you to set the EtCO2 appropriately from normocarbic to hypercarbic (or hypocarbic). More information on this can be obtained from the manufacturer. 2) The BVM was developed in the wake of the Polio Epidemic in Europe (Denmark in particular) in which Anesthesiologist Bjorn Ibsen was called upon to treat scores of patients with bulbar poliomyelitis. Dr. Ibsen utilized the Waters apparatus (by Ralph Waters, Univ of Wisconsin Madison) which used an anesthesia bag on a absorbent canister. The… Read more »

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5 years ago

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Nikolay Yusupov

Dr. Ducanto the unit is a nice toy, it’s nice to have that’s all. It still is not a replacement for a standard BVM (as BVM does not have to be pneumatically powered like the Oxylator to function plus it has a PEEP Valve Adaptor and most first responders will know how to use it had you asked for assistance) and it’s not a replacement for a transport ventilator (Oxylator is pneumatically powered and has no PEEP).

It does not replace a BVM, has no PEEP and is greatly inferior to a Transport Ventilator (with Pplat, PEEP, Basic Modes which is battery powered).

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5 years ago

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rfdsdoc

great work Jim and Scott! The Oxylator is a great innovation in resuscitation care, especially for prehospital setting. I have to provide support for the much maligned BVM or self inflating manual resuscitator, though! That is still too, a simple and resilient design and it does something that the Oxylator cannot…work without any gas supply! Having run out of oxygen in the prehospital setting, this I find can be a very handy thing! The oxylator has an adapter gas cable that blends the oxygen/air mix to reduce FiO2. aS we all know, variable FiO2 can be handy in certain conditions. It also allows you to preserve your oxygen supply. I concede in the hospital setting this is not an issue but it is very much so, prehospital! the point is we need to train to do things better. Whether that is train to use the BVM better, or train with a better device like the Oxylator. I really like the feedback that the Oxylator gives to the user with the clicks. you can make a BVM give feedback with capnography but the audible clicks I find grab attention more…folks can still have trouble believing the ETCO2 but find it difficult… Read more »

Yes, definitely still need a bvm for back-up if the O2 runs out, but the oxylator should use less O2 than a BVM overall. The minute ventilation of the oxylator is right in the sweet-spot for pretty much any pt except severe acidosis. Should get you in the PaCO2 ~35 mm Hg range. The approval of the PEEP adapter is key.

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5 years ago

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jducanto

Hi Mihn,
The Oxylator is the device for the initial Resuscitation, the preoxgenation and ventilation during airway management and the transport to the aircraft or vehicle. You try to avoid bringing sensitive transport ventilators into places that can ruin them, like water filled ditches, etc… The Oxylator, in contrast will work in water (and shortly will be shown to actually work underwater), so it has an unheard of durability for an automated ventilation device.

The EtCO2 can be regulated with a flow control hose. This flow control reduces the minute ventilation by reducing the flow through the device from 30 lpm down to as low as 15 lpm. End-tidal CO2 monitoring is mandatory with the use of the flow control hose. We left this detail out of the discussion, as we intended this presentation to be an introduction to the device.

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5 years ago

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David Hersey

Hello,

Very interesting!!

The Oxylator sounds like a much improved Flynn Resuscitator I learned about back in the day when I did my military medic course. I totally forgot about it.

Excellent topic! In researching Oxylator compatablilty issues I came across this language in the FAQ section for the ResQPOD ITD.
Can I use the ResQPOD with the Oxylator?
No. In the automatic mode, the Oxylator provides a continuously positive airway pressure that is harmful for the patient, with or without the ResQPOD. This continuously positive airflow interferes with the ResQPOD’s ability to create a vacuum (negative pressure). ACSI and the American Heart Association discourage the use of the Oxylator in the automatic mode during CPR, it will decrease circulation.

Thoughts? Should the Oxylator not be used in automatic mode in the setting of arrest?

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5 years ago

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jducanto

Hi Chip, I do challenge the statement in that FAQ from the ResQPOD–the positive pressure from the Oxylator is not harmful to the patient–it simply neutralizes the Impedance Threshold function of the ResQPOD when the Oxylator is used in Automatic Mode. If using the Oxylator with the ResQPOD, you simply use the Manual Mode, with the periodic press and release of the O2 Release button. Once ROSC occurs, you would remove the ResQPOD and set the Oxylator to Automatic mode. You can use the Oxylator in the Automatic mode during cardiac arrest, just not with the ResQPOD. But if the Oxylator is utilized without the ResQPOD, something very interesting occurs: Continuous chest compressions with simultaneous continuous active ventilation. The Oxylator can ventilate on the up-stroke of CPR, all while continuing to limit the inspiratory flow rate (to reduce the chance of gastric insulation) and limit pressure (to reduce the impairment of venous return during CPR). Recent data from Paul Dorian M.D.’s group in Toronto is showing a similar improvement in coronary artery perfusion pressure during CPR in a swine model to the ResQPOD (see the following reference: Hu, X., Ramadeen, A., Laurent, G., So, P. P.-S., Baig, E., Hare, G.… Read more »

Chip, I have the same trepidation of automatic mode compared to intermittent in cpr; as ZEEP or even negative pressures during upstroke of compression seems essential for venous return. I think for mask ventilation (as in no SGA or ETT), the oxylator on automatic is markedly superior to the alternative of stopping after every 30 compressions. The oxylator will sneak in breaths between compressions. So if I had my druthers during CPR, oxylator on automatic with a mask and then as soon as you have an SGA or ETT, switch to intermittent holding down the button until a breath is delivered every 6 seconds.

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5 years ago

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Bill Clark

If the flow is fixed at 30 lpm what happens if the patient is spontaneously breathing with flow rate demand higher than 30 lpm? I have been at codes where the patient seems to be “sucking” the bvm with high inspiratory flows. Would the fixed 30 lpm be detrimental in these cases?

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5 years ago

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jducanto

The Oxylator is open at the top (at the exhalation valve) and will permit the patient to entrain room air if they demand more than 30 lpm on the I-phase of ventilation. It sounds a little like the sounds that Darth Vader makes when he is breathing, so it is totally obvious when this occurs (unless you are in a noise filled environment like a helicopter).

unless you add the PEEP valve (even on zero) (have I mentioned how much this device needs the PEEP valve adapter approved). At that point, the pt will be a little frustrated, but will only get 100% fiO2. This is the same situation as in most BVMs.

[…] yet another demonstration of why you ‘don’t have time not to use social media’. Weingart also talks to Jim Ducanto about the oxylator – and interesting device designed to overcome the shortcomings of the traditional […]

Hi guys,
Don’t judge a book by it’s cover–the device is reusable (does not have a projected number of uses at which it needs to be replaced, like some devices) and is actually made on machine tool machinery, not cast like a cheap disposable device. The Delrin plastic is pretty robust and machinable.

Anyway, I hope you go to the trouble of getting your hands on one and putting it through its paces. They are available on the used equipment market for a discount, but these are usually models “diverted” from the military in the US, always without proper authorization. You’ll know this if the Oxylator is grey–the civilian ones are white. If you buy a grey one, it came from Uncle Sam.

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4 years ago

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Patrick Wanner

Another question would be how much a bad outcome costs – those are costs never factored in, since one just assumes that all cardiac arrests aspirate, the guy was a difficult mask, it was fate, etc. How much are you willing to bet that you are not getting any air into the stomach in your next difficult mask? Here’s another question: how much is an extra pair of hands worth in your next cardiac arrest – with the Oxylator you not only have an excellent oxygenation device, but you have a pneumatic ventilator the size of a fist in your hands. Check out Jim’s videos using it to preoxygenate massively obese patients or think about how you could combine it with a supraglottic airway to rapidly establish ventilation during a cardiac arrest and move on to other things, like drawing up meds or actually running the code.